how to think about health promotion ethics · health promotion ethics15-22 and values23-27 has...

1 Public Health Reviews, Vol. 34, No 1

How to Think about Health Promotion Ethics

Stacy M. Carter, BAppSci, MPH(Hons), PhD,1

Alan Cribb, BA, PhD,2

John P. Allegrante, BS, MS, PhD3,4

ABSTRACT

Health promotion ethics is moral deliberation about health promotion and its prac-

tice. Although academics and practitioners have been writing about ethics, and

especially values, in health promotion for decades, health promotion ethics is now

regaining attention within the broader literature on public health ethics. Health

promotion is difficult to define, and this has implications for health promotion

ethics. Health promotion can be approached in two complementary ways: as a

normative ideal, and as a practice. We consider the normative ideal of health

promotion to be that aspect of public health practice that is particularly concerned with the equity of social arrangements: it imagines that social arrangements can be altered to make things better for everyone, whatever their health risks, and seeks to achieve this in collaboration with citizens. This raises two main ethical questions.

First: what is a good society? And then: what should health promotion contribute to

a good society? The practice of health promotion varies widely. Discussion of its

ethical implications has addressed four main issues: the potential for health

promotion to limit or increase the freedom of individuals; health promotion as a

source of collective benefit; the possibility that health promotion strategies might

“blame the victim” or stigmatise those who are disabled, sick or at higher risk of

disease; and the importance of distributing the benefits of health promotion fairly.

Different people will make different moral evaluations on each of these issues in a

way that is informed by, and informs, their vision of a good society and their

understanding of the ends of health promotion. We conclude that future work in

1 NHMRC Career Development Fellow, Centre for Values, Ethics and the Law in Medicine,

School of Public Health, The University of Sydney, Australia.2 Professor of Bioethics and Education, Centre for Public Policy Research, King’s College,

London, UK. 3 Professor of Health Education and Deputy Provost, Teachers College, Columbia University,

USA.4 Adjunct Professor of Sociomedical Sciences in Public Health, Mailman School of Public

Health, Columbia University, USA.

Corresponding Author Contact Information: Stacy M. Carter at [email protected].

au; NHMRC Career Development Fellow, Centre for Values, Ethics and the Law in Medicine,

School of Public Health, The University of Sydney, NSW 2006, Australia.


health promotion ethics will require thoughtfully connecting social and political

philosophy with an applied, empirically informed ethics of practice.

Key Words: Ethics, health education, health promotion, moral philosophy, political

philosophy, public health

Suggested Citation: Carter SM, Cribb A, Allegrante JP. How to think about health

promotion ethics. Public Health Reviews. 2012;34: epub ahead of print.

HOW TO THINK ABOUT HEALTH PROMOTION ETHICS

Ethics is the discipline devoted to moral reasoning about what we should

do. It is traditionally divided into: meta-ethics, concerned with fundamental

questions like “what is good?” and “what are convincing ethical arguments?”;

normative ethics, focused on rules, frameworks or principles for evaluation;

and practical ethics, concerned with the ethics of practices such as

regulating, policing, teaching or medical care.1 Health promotion ethics is a

form of practical ethics.

A substantial literature in bioethics—the practical ethics of medicine

and biotechnology—has existed since the 1960s.2 The public health ethics

literature grew rapidly from 2000,3-13 initially focused on crises such as

pandemics and bioterrorism.14 A small formal and informal literature on

health promotion ethics15-22 and values23-27 has existed for some time,i but

has recently regained attention within public health ethics. Our purpose is

to survey key issues in health promotion ethics, and suggest approaches

needed for this field to flourish.

Defining health promotion is notoriously difficult.26,29-32 In some juris-

dictions health promotion is an occupational category, so health promotion

could be “what those practitioners do.” But many others promote health,

within and beyond public health and medical systems, and health promotion

ethics should arguably also be relevant to them. Complicating matters

further, conditions that do promote health may not be implemented to

promote health.33 Public transportation, urban design and the structure of

markets can promote or undermine health without that intention; a country’s

political culture and system can influence the determinants of health

independent of a formal “health promotion” sector.34,35 This makes a

discussion of health promotion ethics slippery: should we focus only on

activities defined as health promotion, or should we include all activities

i Practitioners’ extensive debate about values in health promotion has often occurred in online

forums, so may not be captured in the literature.28

How to think about health promotion ethics 3

that promote health?33 Finally, the boundaries between health promotion

and the rest of public health are unclear, so health promotion ethics and

public health ethics may not be meaningfully different. There is no absolute

solution to these problems: we can only suggest a working conception of

health promotion. To do this, we will distinguish between health promotion

as a normative ideal, and health promotion as it is practiced. These can, but

do not always, overlap.

The normative ideal of health promotion arises from a 30-year-old

discourse, found in the Alma-Ata Declaration, the World Health Organization

(WHO) “Global Strategy for Health for All by the Year 2000,” and the

Ottawa Charter for Health Promotion.23,36,37 Bauman and colleagues suggest

that Alma-Ata and “Health for All” created health promotion out of health

education,ii promoting a then-radical account of health as more a product of

social conditions than of clinical services, and emphasising equity,

empowerment and justice.26,29,38,39 The Ottawa Charter powerfully asserted

this account, listing “fundamental conditions and resources for health” as

“peace, shelter, education, food, income, a stable eco-system, sustainable

resources, social justice, and equity.”23 We think this ideal form of health

promotion has two main distinguishing characteristics. The first is its vision

of citizens: as active participants in and potential authors of their own

health, people with whom health promotion practitioners should work

directly and, to some extent, be guided by when forming goals and strategies.

The second is its focus on increasing the equitable availability of the

conditions and resources that improve health, including through structural

change and advocacy.iii,34 Although this will at times overlap with risk

reduction strategies, it emphasises primary prevention: promoting health

for everyone, whether they are at low or high risk of developing disease.43

On this idealised account, health promotion becomes that aspect of public health practice that is particularly concerned with the equity of social arrangements: it imagines that social arrangements can be altered to make things better for everyone, whatever their health risks, and seeks to achieve this in collaboration with citizens.

As it is impossible to cleanly separate health promotion from other

aspects of public health, much of what follows will be relevant to public

health in general. Our idealised account of health promotion is intended to

reflect its character, rather than provide a watertight definition; analysing or

ii The role of a health educator was clearer, of a health promoter looser. So it may have been

easier to develop a procedural ethic for health education than for health promotion.20

iii This initial commitment may now be diluted by neoliberal individualism and behaviourism.26,40-42


defending it in detail is beyond the scope of this paper. Instead we will

focus on two underlying ethical questions:

1. What is a good society?

2. What should health promotion contribute to a good society?

These questions are relevant to practitioners, but also to anyone interested

in health as a moral concern, or in health promotion as a political or social

enterprise.

The practice of health promotion varies globally and is not always

consistent with the idealised account.26,43,44 Because practice cannot be

predicted from the ideal, health promotion ethics needs to engage the diversity

of health promotion practices. Thus, in the latter part of the paper, we ask a

third question: What ethical issues arise in activities intended to promote

health? Answers to this question are relevant to anyone who attempts to

improve the health of communities, including health promotion practitioners.

WHAT IS A GOOD SOCIETY?

Here we present an abridged account of some versions of the good society

that appear in the public health and health promotion ethics literature. Most

of these draw on political or moral philosophy. They are relevant because

the intention to promote health or related good things can only be evaluated

against our conception of a good society.

In one version of the good society, the population as a whole is made as

healthy as possible using available resources. This utilitarian view prioritises

maximising population health without much concern about who benefits or

misses out. An alternative good society, strongest in American scholarship,

emphasises the liberty of citizens as the most important good. This vision

arises from libertarianism and some forms of liberalism, and only condones

interventions designed to stop individuals from harming each other.45

Another tradition, “justice as fairness,” builds on the work of John Rawls to

focus on fair distribution of good things (whether health, quality of life,

wellbeing, money or opportunities), with a particular concern for the least

well-off.46 Yet another good society, drawing on classical Greek scholarship,

emphasises the ability of citizens to participate actively in local civic life

and live in accordance with their values.47 A tradition in Western European

scholarship emphasises solidarity—willingness to stand together, share

burdens and help one another—as an important characteristic of a good

society.48,49 Although we have disaggregated these visions to clarify their

differences, in practice they often overlap or cluster. The normative ideal of

health promotion corresponds to certain visions of the good society,


particularly to the idea that a good society is a just society. The Ottawa

Charter, for instance, strongly asserts the importance of equity.23 The ideal

also resonates with traditions that emphasise civic virtue and solidarity.

However, because ideals and practices are not always aligned, none of these

values can be taken for granted in practice.42,43

WHAT SHOULD HEALTH PROMOTION CONTRIBUTE TO A GOOD SOCIETY?

What should the goals of health promotion be? Or: what should health

promotion contribute to a good society? The answer might seem obvious:

health promotion should promote health, so what health promotion should

contribute to a good society is improved health.

This is not straightforward, however, because there is little agreement

about how health should be defined.38 We discuss definitions of health in

this section not to derive the perfect definition, but because a useful working

definition is needed, for two reasons.29 First: so health can be distinguished

from other good things, to allow precision about goals. When are we

seeking to improve health? When to provide different good things? How is

health related to these other good things? Second: so that activities that

either promote health or are intended to promote health can be identified,

because these, at least in one sense, constitute health promotion.

In the late 1970s, definitions of health were divided into two main

camps: “negative” and “positive”.29,30,50 Christopher Boorse sought to

develop a value-free, or “biostatistical” definition,51 based on functions

such as reproduction or survival. Those with “functional abilities below

typical efficiency” were diseased;51 health was the absence of such disease

(thus a “negative” definition).iv On this definition, health promotion would

entail, e.g., finding individuals with below-typical reproductive function,

and improving their function to typical levels. In stark contrast, the 1978

Declaration of Alma-Ata applied the WHO’s 1946 “positive” definition of

health as “a state of complete physical, mental and social wellbeing, and

not merely the absence of disease or infirmity.”36,53,v On this definition,

iv This account is much criticised (e.g., as relying on relative judgements and ignoring things

we commonly understand as health).29,52 v This account is also much criticised: e.g., Bok argues “it has been variously called masterful

or dysfunctional, profound or meaningless; defended as indispensable in its present formulation,

seen as needing revision, or rejected as inviting the medicalization of most of human existence

and abuses of state power in the name of health promotion.”54


health promotion is charged with enabling every citizen to attain complete

wellbeing.26 This stirring aspiration is an impossible task, and set health

promotion up for an inevitable gap between rhetoric and practice.55,vi

More recent “mid-range” or “welfare” definitions of health sit between

the negative biostatistical and positive wellbeing accounts.29,30 In the late

1980s, Lennart Nordenfelt defined health as the ability to “fulfil vital

goals.”56 Vital goals were those that, when fulfilled, allowed a person to

experience a minimum acceptable degree of welfare in the long term.vii,viii

David Seedhouse, later but similarly, defined health as the conditions that

allowed people to work towards, or to fulfil, their “realistic chosen and

biological potentials.”58 His main point was that health promotion must

accept an open-ended conception of health:59 health will be different for

each person, because each person’s chosen potential is different, reflecting

their values. These definitions, admirably, allow space for individuals to

live the life they choose. But they are practically problematic. They would

require that health promotion either employ strategies compatible with

vi David Buchanan wrote extensively about wellbeing as an end in health promotion.47 In

philosophy, an “end” is good in itself; a “means” is good because it will get you something

else that is good. Buchanan critiqued the WHO definition for conflating health and wellbeing,

and for suggesting health was an end in itself. Health, he argued, is an instrumental good like

money: simply a means to greater ends, not to be pursued for its own sake. Buchanan proposed

we should strive not for health, but for eudaimonia, a complex concept from classical Greek

scholarship, which involves the ability to evaluate one’s own desires. “The good life”

Buchanan argues, “is the life spent seeking clearer understandings of values we think

important to realise and striving to live our lives more closely attuned to those values.”47 What

matters is to cultivate, in citizens, the mindfulness and wisdom required to continuously

consider their own values and live in keeping with them. Buchanan makes this argument to

resist what he sees as the rise of scientifically defined, individualistic, biomedical goals in

health promotion, an over-emphasis on bodily health as an end in itself rather than a means.

Buchanan’s theory is inspiring, with much to offer, but does not clarify why health promotion

should be the institution charged with the monumental goal of creating wise citizens. vii This introduces normative questions, e.g.: What should count as a vital goal? What level of

welfare is an acceptable minimum? Might we underestimate this minimum because we have

lowered our expectations? Who gets to decide?viii Venkatapuram recently combined Nordenfelt’s account with Nussbaum’s work to define

vital goals. Nussbaum argued that a dignified human life required the ability to achieve all of

the following, to a reasonable threshold: life, bodily health, bodily integrity (i.e., freedom

from torture and other violence), to be able to use one’s senses, imagination, thought and

emotions, to be able to reason about one’s life goals, to have opportunity for sympathetic

bonds with other humans and concern towards other species, to be able to play, and to have

control over one’s environment. Venkatapuram proposed that these can be thought of as vital

goals: thus health is the ability to achieve a reasonable threshold of each of them. However,

like the WHO definition, this account is extremely broad, so may not help distinguish the

goals of health promotion from those of other practices, or health policy from public policy in

general.52,57


everyone’s goals or potentials—likely to be impossible—or so tailored to

individual goals that health promotion could only be delivered in a one-to-

one relationship, and could no longer engage in advocacy, structural or

community-level change.

More recently other authors—Alan Cribb,29 and Madison Powers and

Ruth Faden60—have produced definitions that better distinguish health

from competing goods, and thus better identify health-promoting activities.

We will characterise these definitions as useful, restricted and contextualised.

Cribb summarises like this:

“It seems to me that if we stick fairly close to the biomedical con-

ception [of health] but combine aspects of wider conceptions with it

we get close to a workable model of health which allows us to

prevent some of the extremes of indeterminacy. I tend to use “health”

to refer to “the absence of illness” where illness refers roughly to the

object of healthcare practice rather than that of clinical science...”29

Cribb’s, and Powers and Faden’s, definitions have similar characteristics.

They are useful, rather than absolute. They restrict health to the domains of

the body and the objects of healthcare (loosely, what health means in

ordinary language). And they connect this narrower definition to a context. Cribb argues that health must be understood as social and as only one of

many “goods”. Health policy is part of public policy more broadly and is

likely to deliver benefits other than health, and health must be weighed

against other gains from policy decisions. Health is also social: it is socially

determined, understood in a social and historical context, and negotiated in

social relationships.29 Thus we can retain a narrow definition of health but

recognise it is socially caused and connected. Powers and Faden, meanwhile,

set their restricted definition of health into a broader definition of human

wellbeing. Health, for them, is just one of six dimensions of wellbeing: the

other five are: personal security, reasoning, respect, attachment and self-determination. Everyone, they propose, has something like a fundamental

right to achieve a sufficient threshold of each of these dimensions: a just

society will provide this. The role of public institutions is to serve social

justice, that is, to work towards sufficient wellbeing, in each of its six

dimensions, for everyone.ix Individual public institutions might specialise in

one dimension (e.g., health), but they must, overall, be committed to social

justice, which means that they should not promote their “specialist”

dimension while undermining other dimensions (e.g., they should not

encourage disrespect for obese people to improve population health).60 This

approach discourages blindly pursuing population health as an end in itself.47

ix Like Nordenfelt’s definition, this raises the question of how such a threshold can be identified.


These recent definitions of health suggest an overarching goal and a more

specific objective for health promotion practice. The overarching goal would

be to help ensure sufficient wellbeing in all its dimensions for everyone (that

is, to work for social justice).60,x The specific objective of health promotion

would be to improve health, understood via a useful and restricted definition

set in a social context and in the context of the other dimensions of wellbeing.

Given the overwhelming evidence that health is socially as well as biologically

determined, the goal of health improvement will often need to be achieved

via the mechanism of broader economic and social improve ment.61,62 How-

ever, a restricted definition prevents health promotion practitioners or others

from doing whatever they please in the name of health, and requires at least

a credible explanation of how an intervention might improve health.29,61,63

These definitions also highlight the moral importance of considering the non-

health consequences of health promotion actions, as health policy is only one

aspect of public policy, and health should not be pursued at the expense of

other dimensions of wellbeing.33,60

WHAT ETHICAL ISSUES ARISE IN ACTIVITIES INTENDED TO PROMOTE HEALTH?

Thus far we have identified broad ethical currents underlying the normative

ideal of health promotion. These currents—especially those around ideas

of justice and community—are arguably the core values that health

promotion practitioners use to explain and justify their practices.43 We have

also begun to indicate some potential gaps between ideals and practices. In

particular we have argued that, when it comes to practice, the concerns with

justice and community embedded in early health promotion discourses

should be disentangled from an open-ended conception of health, and

instead connected to a useful, restricted and contextualised conception.

In this section we focus on ethical debates in health promotion practice.

These debates reflect, and feed into, the two issues we have already

considered: visions of the good society, and the proper goals of health

promotion.xi Ethical discussions about the practice of health promotion can

x Powers and Faden argue that public institutions are obliged to work towards justice. While

health promotion may be more explicitly committed to justice in its rhetoric, in their view all

aspects of public health, as a public institution, should serve justice. xi “Reflection” is thus a two way process: answers to health promotion practice dilemmas will

reflect a vision of health promotion and the good society; conversely these visions should be

engaged with everyday practice.


be gathered loosely under four intersecting themes, echoing the value

tensions rehearsed above. Considered together, they question whether and

how ideals of justice and community can be operationalised in real-world

contexts without unacceptable ethical costs. Although they intersect, we

will discuss them separately:

1. how health promotion might impinge on, or enhance, the freedom or

autonomy of citizens;

2. health promotion as a source of collective goods or benefits;

3. victim blaming and stigmatisation; and

4. how the benefits of health promotion are distributed.

Two more general observations about ethics in health promotion

practice; first, doing health promotion ethics requires using and critiquing

evidence.64,65 Outcomes or consequences (especially benefits and harms)

are central to ethical evaluation. However, the evidence base in health

promotion, particularly regarding the effects of complex interventions, is

often limited,64,66 so decisions must be taken in the context of uncertainty.

Second, ethical reasoning requires more than recourse to codes of ethics.

Close attention to the strengths and weakness of ethical arguments and to

the meaning of concepts is needed.64 There are several codes of ethics in

this field (e.g.67-70). Their purpose is to codify—to provide a condensed list

of rules for action—and their brevity makes them useful for busy pract-

itioners. However, they are most useful when seen as prompts to, and not

substitutes for, moral deliberation.

Health promotion and the freedom or autonomy of citizens

An early and central concern in health promotion ethics, particularly in

American scholarship, has been incursion on freedoms or liberties that

matter to individuals.18,71-74 Individual freedom is undoubtedly morally

important; this is most clearly recognised in Western liberal democracies.

In clinical ethics, respect for autonomy—generally operationalised as

consent—marks out this area of concern.75 But in health promotion, consent

is harder to rely on: it is difficult to know what should be consented to, who

should consent, and what should be done when there is no community

consensus.33

Empowerment has often been suggested as a health promotion strategy

to respect freedom. Here Braunack-Mayer’s analysis is useful.84 She

argues—consistent with our discussion above—that the proper end of health


promotion is health improvement: empowerment is simply a means.xii

Empowerment may not be achievable; empowerment strategies may assist

some community members to dominate others, or encourage them to

demand ineffective or harmful interventions, a concern echoed by prac-

titioners.70 So empowerment should not be pursued as an end in itself.

Instead, expert or “top down” health promotion judgements, informed by

theory and experience, should be informed by “bottom up” judgements of

community groups, and vice versa, until a reflective equilibrium is reached.

Empowerment thus becomes a means for reaching this equilibrium, not a

go-to strategy for protecting freedom.84

So if empowerment cannot help us solve the problem of incursions on

freedom, what might? The early literature in particular focused on

identifying—and arguing against—actions likely to undermine freedom.

These authors tend to work with a particular, limited, version of freedom,

referred to as “negative freedom”: the freedom to be left alone, or not to be

interfered with.xiii,78 They worry about persuasion (encouraging people to do

or believe something through argument), coercion (imposing on the will of

others using threats or force), or most notoriously, paternalism. Paternalism

gathers several, usually three, meanings into a single word: interfering with

a person’s autonomy or liberty, doing so without their consent, and doing so

for their own good.xiv,76 It is possible to justify all of these, depending on our

view of a good society, and on the particular case.45,77

Persuasion is the easiest action to justify. Alastair Campbell, for

example, argues that persuasion can respect people’s autonomy if we are

clear that we are persuading, do not distort the facts, argue overtly rather

than influence covertly, and remain independent of vested interests.79

Although respectful persuasion is clearly possible, many health social

marketing campaigns instead engage in what Campbell calls “indoctrination,”

usually in the name of “cut through” in a competitive media market.

xii This parallels sociological critiques of health promotion. “Positive” sounding discourses

around empowerment or enablement are often, in practice, embedded in power hierarchies,

systems of surveillance and restrictive conceptions of ends. So we have to examine both ideals

and practices, asking what vision of a good society they assume and what they produce in the

social world.xiii Basic liberties, and non-interference in them, are very important (e.g., freedom from

wrongful imprisonment or torture, and freedom of political expression.) Unfortunately

arguments focused on negative freedoms tend to suggest that more trivial freedoms, such as

the freedom to make unfettered consumer choices, are of equivalent moral importance to these

much more significant freedoms.xiv In political discourse paternalism is often equated with a “nanny state”.


Coercion is a different matter. It is generally accepted that public health

interventions should use the least coercive means available,80 and for good

reason: past coercive policies (e.g., forcing people to have HIV tests early in

the epidemic) frequently undermined trust in public health as an institution.4

Health promotion is not immune: for example, employees might be forced to

participate in a workplace health exercise program.16 So when might coercion

or paternalism be justified?xv The most common allowances are in instances

where interventions stop people from harming one another rather than from

harming themselves (e.g., mandatory immunisation schemes to prevent

hospital staff from infecting their patients and families or school children

from infecting their peers), or when interventions interfere with actions that

are ill-informed, or involuntary, or more controversially, not in keeping with

a person’s most deeply-held goals.38,76,xvi Such conditions can be used to

evaluate interventions, but they work best for those—like the workplace

health program—where something is being done directly to individuals.

They are less helpful for the structural, community or advocacy interventions

that we have suggested might characterise health promotion. One could

argue, for example, that high fat, high sugar foods should be regulated

because individual consumers do not fully understand the risks, or do not

mean to buy these foods, or that eating them is inconsistent with what they

really want for their life. But these are difficult to demonstrate convincingly,

and matter most to those, such as libertarians, who hold negative freedom—

the freedom to be left alone—to be the most important moral end.

There is an alternative that is more compatible with health promotion: the

capability approach.57,85,86 The capability approach contends that people

should be free to achieve wellbeing, and that this relies on them having real

opportunities to live and to act in accordance with their values.85,xvii The

capability approach encourages us to assess both the opportunities available

to individuals, and those available to a whole community or nation. And it

approaches freedom quite differently to the approaches described above. It

does not assume that individuals should be completely independent, or that

their most important interest is to be left alone. Rather, it emphasises that

xv Dworkins’ typology of more or less justifiable paternalisms is generally considered the

standard.81

xvi In Western liberal state policy, “Nudge” is currently influential, employing an allegedly

unproblematic type of paternalism, “libertarian paternalism,” and based in behavioural

economics and cognitive psychology.82 See detailed analysis and responses in the American

Journal of Bioethics.83

xvii Writers in the capabilities approach would say “to be and to do” in accordance with their

values. Martha Nussbaum’s list of “central capabilities” required for a dignified human life is

provided in Note viii.


people’s autonomy depends on their social, relational and political environ-

ment, and that they have a moral stake in that environment providing them

with real opportunities, including the opportunity to be healthy. Thus, for

example, rather than reducing our freedom, state taxation, subsidies and

regulations that make it easier and cheaper to buy healthier food could

provide real opportunities to be healthy, something that most people value.xviii

Autonomy remains important, but a more sophisticated conceptualisation

alters the discussion of freedom. Instead of asking “is this health promotion

strategy instituting a paternalistic nanny state?” we are encouraged to ask “is

this health promotion strategy providing individuals and communities with

real opportunities that they are likely to value?”

Health promotion as a source of collective goods or benefits

Collective actions and collective goods have particular moral significance

for health promotion, because its ideal form has emphasised community.

This emphasis appears to be a present source of tension in health promotion.

Health promotion is commonly criticised for becoming increasingly

individualistic;26,40-42,88 simultaneously practitioners affirm their commitment

to working with and for communities.43,70

We will deal with individualism in the next section, but first consider

arguments regarding the moral significance of community. There is a long

tradition of valuing community in political and moral philosophy; this is

becoming increasingly prominent in public health and health promotion

ethics.89,90 It reflects a vision of the good society in which shared values, the

common good or solidarity are important and, as in the capability approach,

people are thought of as potentially benefiting from, not just being

threatened by, the fact that they live in a community.

This is, in part, about the existence and benefit of collective goods.

There is a type of collective good that is simply the sum of individual goods

(e.g., a lower average HIV prevalence in the population is the sum of many

individuals not having HIV). But there is another kind of collective good

that is greater than the sum of its parts: goods that can only exist through

collective action, and which exist at a collective level. Widdows and Cordell

suggest that these goods can be identified as the ones that we think of as

xviii Libertarians often suggest that the only way to preserve consumer freedom is to limit

intervention to information provision (e.g., food package labelling). The capabilities approach

suggests that having to carefully analyse the labels of every food product to determine whether

it is unhealthy is in fact a burden. Regulation to reformulate food and/or restructure the market

to allow people of all levels of ability and wealth the opportunity to purchase healthy food

easily would provide a more meaningful freedom.87


“its” goods, that is, the goods of “the community” as a whole, as opposed

to “their” goods, that is the goods of the individuals who live in the

community.89 So, for example, if we say “West Haven is a walkable city” or

“France has high quality, affordable childcare services” or “Denmark’s

food supply contains almost no transfats,” we are talking about goods that

accrue to the entire community, to the body politic. Most importantly, they

are goods that individuals cannot achieve for themselves: they can only be

achieved through collective action. They are also better seen as opportunities

(in the capabilities sense) rather than interferences. And the ideal form of

health promotion discussed above is particularly well-oriented towards

such goods. Because these goods have special moral significance, this

suggests that in evaluating health promotion activities we might ask: “Will

this benefit everyone?” and “Are we focusing on outcomes that can only be

achieved through collective action?”

Victim blaming and stigmatisation

Individualism, and collective goods, can be connected by considering the

wrongs that health promotion might do to people and communities.xix In

short, health promotion practice seems likely to do wrong when it is method-

ologically individualistic, that is, when it understands social phenomena as

largely a product of individual agency, of the goals, beliefs and actions of

individuals, rather than focusing on collective goods and actions.44,88,91 This

entails an oversimplified model of disease and risks two main wrongs:

victim blaming and stigmatisation.xx

The potential for health promotion to “blame the victim” has been a

longstanding concern in health promotion ethics.92,93 This expresses an

important worry: is it just to consider individuals personally responsible for

their health? As with all moral issues, a view of individuals as personally

responsible tends to travel with a particular view of the good society, one

that imagines people as fully rational, informed and in control of their lives,

and thus values the protection of their negative freedom as a crucially

important moral good.

xix Unjustifiably interfering in someone’s freedom, already considered, is also a wrong.xx Note that victim blaming and stigmatisation are important wrongs, but not the only wrong

we should be concerned about: e.g., in an American setting, employers may buy-in health

promotion programs and then cut health insurance cover on the grounds that employees

should be healthier.16 Each strategy needs to be considered case by case. Also: victim blaming

and stigmatisation are widespread social trends. We are suggesting not that health promotion

practitioners are especially guilty of them, but that they are especially obligated to avoid them

because they are inconsistent with the goals and values of health promotion.


There are two key points to make here. The first is to distinguish causal

from moral responsibility. We might, for example, prepare a meal for our

family and in so doing unwittingly give them food poisoning; in this case

we would be causally, but not morally, responsible.29 The second point to

make is that there is no clear line between private and public actions in

health: the strong evidence on social determinants shows that responsibility

for health is diffuse.29,62 We all engage in practices that contribute to our

health, but at best are only partially responsible for our health status.

Further, empirical evidence shows that people tend to allocate responsibility

to individuals to make sense of health problems, so we may be less likely

to recognise this when it occurs.xxi,16,94

Many health promotion strategies may risk allocating responsibility

unjustly. Workplace-based health promotion, for example, may give

employees tools to endure a health-undermining workplace rather than

attempting to change the institution.16 Social marketing campaigns

frequently address viewers as individuals, exhorting them to change their

behaviour and suggesting that this is easy despite the overwhelming

evidence to the contrary.64,95,96 Given that these campaigns are widely

thought to act on social norms, they arguably reproduce the tendency for

members of the general public to unjustly allocate responsibility for health

risks or diseases to individuals.

The second potential wrong is that negative messages about disabilities,

illnesses or risks will increase the stigma experienced by people who are

already living with those disabilities, illnesses or risks.64,97 Identification

and labelling of differences between people can be benign, but become

stigmatising when certain identified groups are stereotyped and perceived

as other—as “not like us” or deviant—leading to loss of status and

systematic discrimination against people living with conditions such as

mental illness or obesity.44,98

Health experts sometimes suggest that stigma is a useful tool for

population-level communications. This is consistent with simplistic health-

maximising utilitarianism: an impoverished view of the good society as

one that should deliver the maximum possible amount of health on average.

On this view, stigmatisation that “works” to improve health is morally

acceptable. This argument is clearly ethically problematic. It focuses on the

health dimension of wellbeing at the expense of other dimensions, such as

respect.60 It ignores evidence that stigma makes life more miserable and

xxi Note also that the empowerment discourse may imply that individuals should be able to take

charge of their health.92


stressful and so is likely to have direct health effects.98 It fails to recognise

that being stigmatised travels with disadvantage, that stigmas tend to

cluster, and that stigmatised conditions are only partly the responsibility of

the individuals who experience them, such that these individuals should not

be held responsible unless the other involved parties are also held

responsible.29,44,98 All of these problems make such stigmatisation, whether

deliberate or unintentional, unjust.

Health promotion practitioners do not always have control over the work

they do. They may be deeply personally committed to building respectful

relationships with communities over time, building community capabilities,

and ensuring sustainability, but be required to implement standardised and

potentially problematic interventions.43 Managerialism can encourage

“ethics avoidance”, with scientific and managerial rationality overwhelming

ethical concerns.29,99 David Buchanan, who developed one of few total

theories of health promotion ethics in 2000 (Note vi), reacts explicitly

against such rationality. He advocates responding to local situations rather

than applying standardised solutions, acknowledging the importance of

being trusted by communities and building solidarity, thinking of people not

as faceless aggregations of statistics, or as “targets” for punishment and

reward, but as citizens who are worthy of, and stand to benefit from,

respectful engagement.47 This suggests the importance of accountability to

communities,80 and suggests two different sets of responsibilities in health

promotion. First, planners and policymakers should aim to create programs

and strategies that minimise the risk of harming or wronging citizens,

whether through stigmatising them, making them falsely personally

responsible, or in other ways. Second, individuals on the “front-line” of

health improvement, whether in official health promotion roles or otherwise,

should deal respectfully with those whom they encounter and, where

practicable, critically analyse, challenge and resist policies that fall short.

How to distribute the benefits of health promotion

Our final ethical question is: how should the benefits and burdens of health

promotion be distributed? Asking this entails a vision of the good society as

one that fairly distributes resources, opportunities or wellbeing. Powers and

Faden’s theory is useful here. They argue that those in society who are least

well off experience “densely woven systematic patterns of disadvantage,”60

that is, they experience many forms of disadvantage simultaneously. They

are likely to have less money, poorer housing, less work and lower status

work, poorer quality of education and so on, all at once. These interact and

compound, worsening disadvantage. So those least well-off would require


extraordinary good luck or heroic effort to attain even an average level of

wellbeing, usually through no fault of their own.60 For Powers and Faden,

this makes densely patterned disadvantage particularly unjust. Because they

see public institutions as especially responsible for increasing social justice,

they argue that public health and health promotion, as public institutions,

are particularly obliged to intervene in severe disadvantage.

By now it should be clear that we are broadly convinced by and

committed to the normative ideal of health promotion summarised earlier:

focused on the fairness of social arrangements, and on achieving the

conditions that underpin good health for everyone, in collaboration with

communities. For us this entails a reflexive commitment to a vision of the

good society that emphasises social justice and collective goods, informed

not only by moral and political arguments about the nature of the good

society, but also by strong evidence on the social determinants of health,62

and knowledge of health promotion practice. Others will occupy different

positions: for example, a utilitarian who wants to maximise average health

without too much concern for its distribution or the potential ill-effects, or

a libertarian who is most concerned about negative freedom, or someone

focused on eudaimonia at the level of the individual (Note vi).

We emphasise a particular way of thinking about the distribution of

benefits and burdens. People are not all equally autonomous. Those who

have fewer opportunities relative to their fellow citizens are not autonomous

in the same way as those who have more opportunities. Someone with an

excellent education, high social standing, a good job, a supportive social

network, and a warm, dry home in a friendly, safe neighbourhood is

autonomous in a more meaningful way than someone with none of these

things. Conceptualising freedom as opportunity, and understanding health

promotion as an institution obliged to increase the availability of those

opportunities, encourages us to redress this unfairness. Conversely, those

who would emphasise freedom as the right to be left alone would see this

as an intrusion rather than a justice. We are concerned that health promotion

strategies should avoid increasing the existing stigma and unjust allocation

of personal responsibility that multiply disadvantaged people already

experience.98 This is based in our earlier arguments that health should not

be pursued at the expense of other aspects of human wellbeing. But a

utilitarian author may be less concerned about these issues, and a libertarian

may welcome a conception of individuals as personally responsible. Like

solidarity theorists, we prefer collective actions that produce collective

goods, both for their ability to redress disadvantage and their aspirational

qualities. Some collective interventions—such as using national regulation

to reformulate food—will benefit everyone. We think that if fairness is


important, collective interventions that occur in settings or communities—

such as improving urban design, transportation or the availability of fresh

food markets—should be distributed at least equally, if not preferentially,

to disadvantaged communities. However, those who think we have no

special responsibility to the less well-off may not agree.

Goldberg argues that while we should aim to improve everyone’s health,

we should aim to improve poor people’s health more, because they are

currently bearing most of the burden.44 A simplistic utilitarian position

would oppose this contention. Increase average health, the argument goes,

and the least well-off will also benefit: remember Rose’s famous prevention

paradox.xxii,100 We make two points here. Rose’s colleagues have lately

emphasised his egalitarian commitments: that he argued for structural

interventions as beneficial for everyone, including the least well-off.100 And

in practice, “population-level” interventions often focus on altering

behavioural and biological risk factors, rather than facilitating structural

and political change. Identifying and intervening in people with risk factors

(e.g., overweight) tends to benefit the affluent, because they have the agency

required to engage and participate.101,102

We have, anecdotally, heard decision-makers justify such interventions

as “helping the people who want to be helped” and so “focusing where we

can be most effective.” But this is only morally acceptable via a particular

vision of a good society: one in which health is a product of individual

choices and fairness can be de-prioritised. In a recent International Union

for Health Promotion and Education ethics forum, practitioners worried that

they were rarely funded to engage in structural change or address identified

needs in poor communities, but instead were expected to offer interventions

that only already-advantaged people could benefit from.70 For practitioners,

at least, the commitment to justice built into the normative ideal of health

promotion appears to remain a central concern. But despite the ideal, health

promotion practice is often dominated by individualistic interventions.44,88

Current movements in health promotion towards complexity and systems

thinking may help counter this trend;103 however visionary actions from

health promotion opinion leaders, changes within bureaucratic systems, and

modelling from the non-government sector may be required to achieve

long-term change.

xxii Rose observed that populations contain many people at low to moderate risk of developing

a disease, and few at high risk of developing that disease. The prevention paradox is that

greater population health improvement may be obtained via widespread small improvements

in those many at low risk, rather than via dramatic change in those few at high risk.


CONCLUSION

Future scholars of health promotion ethics should self-consciously work

between social and political philosophy on the one hand and applied,

empirically informed, ethics of practice on the other. It is important to be

able to map, and debate, competing normative visions of health promotion,

including but not limited to the normative ideal we have elaborated here.

We should ask how such normative ideals can be defended, but also how

norms change in different times and places. We need to attend to principles

(such as minimising harm) but also to the contexts that shape policies,

norms and practices.

Many unanswered questions with ethical implications remain for future

work. What is health promotion now? Does it still exist? If so, does it bear

any relation to the 1980s normative ideal? How might it be different from

or similar to other aspects of public health practice, and does this matter?

What should it be in future? How can we better understand collective goods

or benefits, and how should we weigh potentially competing goods, such as

maximising average benefit vs. fairer distribution of benefit? When can

citizens be reasonably expected to stand in solidarity with others to improve

everyone’s health? How can we convince decision makers to attend to the

potential harms of interventions as well as the benefits?

Although statements of principle and codes of practice have symbolic

importance, doing practical ethics requires engagement with underlying

arguments and concepts, and also with the details of everyday practice.

Simple prescriptions cannot suffice because every situation is different.

Examining ethical questions requires a conversation: a process of reasoning

back and forth between differing views of the good society and different

exercises of practical wisdom and experience. It requires openness among

all parties to be transformed in the exchange. We hope that the questions we

have posed in this review, and the range of answers we have presented, will

spark an enlivened conversation about both health promotion and health

promotion ethics, and so be of use to policy makers, practitioners and

everyone concerned with the health of communities.

About the Authors: Dr. Stacy M. Carter (PhD, MPH Hons) is a NHMRC Career

Development Fellow at the Centre for Values, Ethics and the Law in Medicine in the

School of Public Health at the University of Sydney. Her work focuses on the ethics

of public health (particularly health promotion, non-communicable disease pre-

vention and cancer screening), and on methodology for qualitative research and

empirical bioethics.

Dr. Alan Cribb (PhD) is Professor of Bioethics and Education and Co-Director of

the Centre for Public Policy Research at King’s College London. He has a particular

interest in the interface between philosophy, social sciences and professionalism.


Dr. John P. Allegrante (PhD) is Professor of Health Education and Deputy Provost

at Teachers College, and Adjunct Professor of Sociomedical Sciences at the

Mailman School of Public Health, Columbia University. His research focuses on

health behavior, health promotion, and health outcomes in chronic disease.

Acknowledgements: Stacy Carter is funded by a National Health and Medical

Research Council (NHMRC) Career Development Fellowship (1032963); research

for this paper was partially supported by NHMRC Project Grant 632679.

Conflicts of Interest: None declared.

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